Table 3 Summary of recommendations

1. Routine investigation for TBI, and consequent TPT, when indicated, should be carried out in all persons with IMID who will undergo immunosuppressive treatment, regardless of the class of drug chosen, if there is no recent history of treatment for TBD or TBI.

CQ1, CQ2, CQ3

Very low

95.0%

2. TBI diagnosis should be considered and TPT indicated in the following situations:

1. TST ≥ 5 mm;

2. A positive IGRA;

3. Signs of lung TBD sequelae in imaging tests (chest X-ray or CT) in the patient not previously treated for TBD;

4. Recent exposure to pulmonary or laryngeal TBD, if there is no clinical, and/or imaging evidence of TBD.

CQ8, CQ10, CQ12, CQ13

Moderate

100.0%

3. In case TST/IGRA are not available:

-Persons with previous history of TBI/TBD treatment: once TBD is excluded, TPT is not mandatory, even in the absence of a TBI test.

-Persons with no history of TBI/TBD treatment: once TBD is excluded, TPT should be recommended in a shared decision with the patient, regardless of the class of medication to be used.

CQ2, CQ3, CQ12, CQ13

Low

95.0%

4. Both TST and IGRA can be used to diagnose TBI in IMID persons, since there is no gold standard test for diagnosing TBI in clinical practice.

CQ4

Moderate

100.0%

5. When screening for TBI in persons with IMID, it is neither mandatory nor recommended to perform TST and IGRA tests simultaneously, and immunosuppressive treatment should not be postponed in order to perform both tests.

If the first test is negative, the other can be considered. TPT should be started at any time if one of the tests is positive.

CQ4

Moderate

97.5%

6. In the event of an indeterminate IGRA test result, it is recommended to repeat the test as soon as possible. If the result remains inconclusive, consider TPT.

CQ4, CQ5, CQ7

Moderate

97.5%

7. If the pre-treatment TST/IGRA test is negative, annual repetition of the test is recommended until the third year of treatment, especially in IMID patients taking TNFi.

After this period, clinical and epidemiological surveillance is recommended during the immunosuppressive treatment, regardless of the class. In persons with a previous history of treatment for TBI or TBD, screening should not be repeated.

CQ4, CQ9, CQ10, CQ12

Moderate

85.0%

8. In IMID, If it is necessary to change the medication, regardless of the class, if there is a previous negative TBI screening, TST/IGRA should be performed annually for the next 3 years, according to recommendation 7.

CQ1, CQ2, CQ3, CQ4, CQ9, CQ10, CQ11

Very low

85.0%

9. In persons with IMID vaccinated with BCG in the two years before starting immunosuppressive treatment, IGRA is preferable to TST for TBI screening.

If BCG was administered more than two years before the introduction of treatment, a positive TST or IGRA result should be interpreted as a diagnosis of TBI and TPT should be started as soon as TBD is ruled out.

CQ4, CQ6, CQ14

Low

100.0%